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Department of
SOCIAL SERVICES

Community Care Licensing


FACILITY EVALUATION REPORT

Facility Number: 195850091
Report Date: 09/13/2024
Date Signed: 09/13/2024 10:33:42 AM


Document Has Been Signed on 09/13/2024 10:33 AM - It Cannot Be Edited

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY

FACILITY EVALUATION REPORT		CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
COMMUNITY CARE LICENSING DIVISION
WOODLAND HILLS N.ASC, 21731 VENTURA BLVD. #250
WOODLAND HILLS, CA 91364



FACILITY NAME:PRESERVE AT WOODLAND HILLS, THEFACILITY NUMBER:
195850091
ADMINISTRATOR:MICHAEL OWENSFACILITY TYPE:
740
ADDRESS:6221 FALLBROOK AVENUETELEPHONE:
(747) 226-5834
CITY:WOODLAND HILLSSTATE: CAZIP CODE:
91367
CAPACITY:60CENSUS: 34DATE:
09/13/2024
TYPE OF VISIT:Case Management - IncidentUNANNOUNCEDTIME BEGAN:
09:50 AM
MET WITH:Susan Weisbarth, Executive Director (ED)TIME COMPLETED:
10:40 AM
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Licensing Program Analyst (LPA) Emily Peraldi conducted an unannounced case management visit at 9:50 a.m. Upon arrival, the LPA met with Executive Director (ED) Susan Weisbarth and explained the reason for the visit.

The reason for today's inspection is to follow up on a self-reported incident report received on 09/10/2024. The report pertains to Staff #1 (S1) placing a cloth over Resident #1’s (R1’s) mouth after R1 attempted to bite S1.

Starting at 9:54 a.m., the LPA conducted interviews with the ED and one (1) staff member. At 10:07 a.m., the LPA conducted a file review and obtained copies of pertinent documents.

Additional report may follow if warranted.

Exit Interview conducted and report was issued.
SUPERVISOR'S NAME: Kristin HeffernanTELEPHONE: (818) 596-4493
LICENSING EVALUATOR NAME: Emily PeraldiTELEPHONE: 818-421-4497
LICENSING EVALUATOR SIGNATURE:
DATE: 09/13/2024
I acknowledge receipt of this form and understand my licensing appeal rights as explained and received.
FACILITY REPRESENTATIVE SIGNATURE:
DATE: 09/13/2024
This report must be available at Child Care and Group Home facilities for public review for 3 years.

LIC809 (FAS) - (06/04)
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